Regulation and expression of IL-32 in chronic rhinosinusitis.

BACKGROUND: Activated T lymphocytes and their interaction with resident tissue cells, particularly epithelium, play important roles in inflammatory processes in chronic rhinosinusitis (CRS). IL-32 is a recently described cytokine, which is expressed in a variety of tissue cells and involved in the pathogenesis of several chronic inflammatory diseases. METHODS: Human sinus epithelial cells were isolated from biopsies and stimulated with different cytokines, which play a role in the pathogenesis of CRS. IL-32 mRNA expression was analyzed using real-time-PCR, IL-32 protein was determined by Western blot and flow cytometry as well as immunofluorescent staining in primary sinus epithelial cells and nasal biopsies from patients with CRS and healthy controls. RESULTS: IL-32 mRNA was upregulated by TNF-α and IFN-γ in primary sinus epithelial cells, whereas IL-1 ß, IL-4, IL-13, and IL-17 did not influence IL-32 expression. IL-32 mRNA expression was significantly higher in human primary sinonasal epithelial cells (HSECs) cocultured with Th1 cells compared with HSECs cocultured with Th0 or Th2 cells. IL-32 mRNA expression was significantly higher in biopsies from sinus epithelial tissue of CRS patients with nasal polyps compared with healthy subjects (P = 0.01). IL-32 was detected in biopsies from patients with CRS, whereas it was scarcely present in control tissues. CONCLUSION: The induction of IL-32 by TNF-α, IFN-γ and Th1 cells as well as its increased expression in sinus tissues from CRS patients with nasal polyps demonstrated a potential role for IL-32 in the pathogenesis of CRS.

Humoral and cell-mediated autoimmunity in allergy to Aspergillus fumigatus.

A cDNA encoding an allergenic protein was isolated from an Aspergillus fumigatus (A. fumigatus) cDNA library displayed on the surface of filamentous phage. Serum immunoglobulin E (IgE) from A. fumigatus-sensitized individuals was used to enrich phage-expressing gene products binding to IgE. One of the cDNAs encoded a 26.7-kD protein that was identified as a manganese superoxide dismutase (MnSOD) sharing 51.5% identity and 67.2% homology to the corresponding human enzyme. Both human and A. fumigatus MnSOD coding sequences were expressed in Escherichia coli as [His]6-tagged fusion proteins and purified by Ni(2+)-chelate affinity chromatography. The two recombinant MnSODs were both recognized by IgE antibodies from subjects allergic to the A. fumigatus MnSOD and elicited specific immediate type allergic skin reactions in these individuals. Moreover, both human and A. fumigatus MnSOD induced proliferation in peripheral blood mononuclear cells of A. fumigatus-allergic subjects who showed specific IgE responses and reacted in skin tests to MnSOD. These observations provide evidence for autoreactivity to the human MnSOD in allergic persons sensitized to an environmental allergen from A. fumigatus who share a high degree of sequence homology to the corresponding human enzyme.

Molecular and immunological characterization of Asp f 34, a novel major cell wall allergen of Aspergillus fumigatus.

BACKGROUND: Although fungal spores have been recognized as triggers of respiratory allergy and asthma, only two allergenic fungal cell wall components have so far been described. METHODS: Eighty-one sequences derived from an Aspergillus fumigatus cDNA library encoding putative allergens were examined for the presence of cell wall components. A new allergen (Asp f 34) was evaluated by Western blots, enzyme-linked immunosorbent assay (ELISA), peripheral blood mononuclear cell (PBMC) proliferation assays, and skin prick test (SPT). RESULTS: The cDNA encoding Asp f 34 contained an open reading frame predicting a protein of 185 amino acids with a molecular weight of 19.38 kDa, showing sequence homology to phiA, an essential protein for the formation of conidia in the genus Aspergillus. The recombinant Asp f 34 was binding IgE from sensitized individuals in Western blots. An ELISA survey showed that 94% of the ABPA and 46% of the A. fumigatus-sensitized individuals tested had Asp f 34-specific serum IgE. Asp f 34 induced allergen-specific proliferation exclusively of PBMCs from patients sensitized to the allergen. Eight patients with anti-Asp f 34 serum IgE tested reacted positively in SPT, whereas four A. fumigatus-sensitized individuals without Asp f 34-specific IgE and eight healthy controls scored negatively. CONCLUSIONS: A cell wall protein of the phialides of A. fumigatus was identified as a major allergen. Asp f 34 belongs to the Aspergillus-specific proteins of the phiA family and has relevant potential for a specific diagnosis of Aspergillus sensitization.

Auto- and cross-reactivity to thioredoxin allergens in allergic bronchopulmonary aspergillosis.

BACKGROUND: Thioredoxins are cross-reactive allergens involved in the pathogenesis of atopic eczema and asthma. Cross-reactivity to human thioredoxin can contribute to the exacerbation of severe atopic diseases. METHODS: Human thioredoxin, Asp f28 and Asp f29, two thioredoxins of Aspergillus fumigatus, and thioredoxin of Malassezia sympodialis were cloned and produced as recombinant proteins. Allergenicity and cross-reactivity to thioredoxins in allergic bronchopulmonary aspergillosis patients were assessed by enzyme-linked immunosorbent assay (ELISA), inhibition ELISA, immunoblot analysis, proliferation assays and skin tests. Molecular homology modelling was used to identify conserved, surface-exposed amino acids potentially involved in immunoglobulin E (IgE)-binding. RESULTS: All thioredoxins, including the human enzyme, bind IgE from patients with allergic bronchopulmonary aspergillosis and induce allergen-specific proliferation in peripheral blood mononuclear cells and positive skin reactions in thioredoxin-sensitized patients. Inhibition experiments showed that the thioredoxins are cross-reactive indicating humoral immune responses based on molecular mimicry. To identify structural surface elements involved in cross-reactivity, the three-dimensional structures were modelled based on solved thioredoxin structures. Analysis of the molecular surfaces combined with sequence alignments allowed identification of conserved solvent exposed amino acids distantly located in the linear sequences which cluster to patches of continuous surface areas. The size of the surface areas conserved between human and fungal thioredoxins correlates well with the inhibitory potential of the molecules in inhibition ELISA indicating that the shared amino acids are involved in IgE-binding. CONCLUSIONS: Conserved, solvent exposed residues shared between different thioredoxins cluster to continuous surface regions potentially forming cross-reactive conformational B-cell epitopes responsible for IgE-mediated cross-reactivity and autoreactivity.

[Trial end-point in chronic obstructive pulmonary disease (COPD): minimal clinically important difference]. / Studienendpunkte bei der chronisch-obstruktiven Lungenerkrankung (COPD): "Minimal Clinically Important Difference".

The concept of the minimal clinically important difference (MCID) is intended to provide a measure of relevance for a statistically applied in patients with COPD. Clinically important differences are those differences relevant to the individual patient and important to the patient's life. However, people's difference in a diagnostic parameter perception of what is important vary. Furthermore, physicians may rate the significance of a particular marker and its difference which can be achieved by a pharmacological intervention differently from the patient. Thus, the major problem with defining an MCID for any measure is that the most important differences, which require the most subtle measures for an individual patient, are likely to have the least general application. Conversely, measures that can be generalised are unlikely to have much individual importance and will be very crude tools for an individual assessment. In medical trials both, statistical rigor and clinical relevance are generally required, and MCID is without doubt a key application tool defining treatment success or treatment failure. This paper gives an update on the concept of a minimal important difference of most relevant parameters in COPD treatment.

[Pulmonary rehabilitation in asthma bronchiale]. / Rehabilitation bei Asthma bronchiale.

Pulmonary rehabilitation for patients with asthma is designed to achieve and to maintain an optimal daily functioning at a health-related quality of life and to increase participation in social and professional life. In this context, rehabilitation is defined as a time-limited treatment programme which systematically employs scientifically-based diagnostic management and evaluation options to achieve a normal life irrespective of the chronic disease. This requires therapeutic interventions that are characteristic for rehabilitation and complete the regular medical treatment in order to minimise the physical, psychological and social consequences of the chronic disease. Examples of those bio-psycho-social disease consequences which are not sufficiently treated by antiobstructive medication are secondary deconditioning and anxiety, social withdrawal, reduced physical activity and reduced participation in social and professional life. In order to antagonise these secondary consequences of the chronic disease, pulmonary rehabilitation programmes utilise expertise from various health-care disciplines that are integrated into a comprehensive programme tailored to the needs of each individual patient. The interdisciplinary team of health-care professionals in pulmonary rehabilitation includes physicians, respiratory and physical therapists, psychologists, exercise specialists, social workers and others with appropriate expertise for example in nutritional therapy. Therefore, pulmonary rehabilitation programmes are not only an integral part of the current German asthma guidelines with clearly defined tasks within a comprehensive long-time management, but rehabilitative treatment options are also cornerstones of the recently released national disease management programmes for bronchial asthma.

[Early diagnosis of chronic obstructive pulmonary disease (COPD)]. / Frühdiagnostik der chronisch obstruktiven Lungenerkrankung. Wie lange reicht die Luft noch?

Since the early detection of COPD is problematic, nonobstructed smokers with a chronic productive cough are initially assigned to the COPD risk group o. Although there is still a lack of evidence that early pharmacological intervention is associated with benefits in terms of disease progression, the earliest possible diagnosis is still considered a desirable goal. For the sooner triggering noxae, such as cigarette smoke, are eliminated, the more positive are the effects on the subsequent course of the illness. When establishing the diagnosis, a careful case history is of particular importance. With the aid of various diagnostic pulmonary function tests, degrees of severity can be differentiated and the course of COPD can be determined. Since the end of 2004, structured therapeutic programs for COPD have become available.

Automated serology with recombinant allergens. A feasibility study.

Diagnosis of allergic conditions is based on skin prick- and/or intradermal tests and on serology. Both methods make use of allergenic preparations and the results mainly depend on the quality of the substances applied and on the reactivity of the subjects. Recombinant allergens can be produced as highly pure proteins. They may contribute to a significant improvement of the diagnosis of allergic diseases provided that the allergens became available in a pure, fully antigenic form suitable for routine assessments. We have studied the diagnostic properties of recombinant Aspergillus fumigatus allergen I (rAsp f I/a), a major allergen recognised by about 60% of the A. fumigatus allergic individuals, to test the feasibility of using recombinant allergens for automated serology in the Pharmacia CAP System, a new solid-phase immunoassay. ImmunoCAPs carrying immobilised rAsp f I/a were produced and evaluated using sera from well characterised patients with allergic bronchopulmonary aspergillosis (ABPA), allergic asthmatics with or without A. fumigatus sensitisation, and healthy control persons. The clinical parameters used for the diagnosis of allergy to A. fumigatus were RAST and skin test reactivity to commercial A. fumigatus extracts. IgE antibodies recognising rAsp f I/a were determined by a direct antigen-specific ELISA and with the newly developed rAsp f I/a ImmunoCAPs. Quantitative results from the two rAsp f I/a detection systems correlated closely, indicating that this recombinant allergen can be incorporated in the Pharmacia CAP System with unaltered antigenic activity. The behaviour of a panel of recombinant A. fumigatus allergens in the Pharmacia CAP System will be evaluated in the near future to assess the potential of recombinant allergens for the automated diagnosis of allergic conditions.

[Acupuncture for chronic pain patients. Treatment outcomes--the role of the acupuncturist]. / Akupunktur bei chronischen Schmerzpatienten. Behandlungsergebnisse--Rolle des Akupunkteurs.

These results are relevant to the choice of appropriate criteria for quality assessment of acupuncture and emphasize the role of patient satisfaction within quality assurance. Pre- and post-treatment differences in a set of pain related measurements were determined using a combination of data from an observational study and a survey of physicians. The following features of the physicians' study were investigated: specialisation, qualification in acupuncture, rate at which patients received acupuncture, use of further, complementary methods in the practice. The results were statistically adjusted according to different basic conditions (case-mix). A total of 4,084 patients with chronic headache, lower back pain or arthritic pain were treated by 1,838 acupuncturists. There were no differences in success for patients treated by physicians passing through shorter (A diploma) or longer (B diploma) training courses in acupuncture. Patients treated by orthopedists showed less improvement than those treated by physicians with other specialisations. However, these differences had disappeared 6 months after the onset of acupuncture.These longer term effects were more pronounced for physicians offering additional complementary methods in their practice. Improvement after acupuncture and patient satisfaction were positively correlated.

[Combination of asthma and COPD: more frequent as considered to be?]. / Kombination von Asthma und COPD--häufiger als man denkt?

Evidence-based national and international guidelines are largely aimed to guide in the diagnosis and treatment of asthma or COPD, but none addresses sufficiently mixed disease states of both disorders, which are ill-defined but very common in the daily routine clinic. This is a consensus report of a workshop on mixed disease. Asthma is characterized by a classical clinical history and physical exam, reversible airflow limitation and a high degree of bronchial hyperresponsiveness. In contrast, history (mostly smoker) and findings in typical COPD are different: COPD patients have little if any bronchial hyperresponsiveness and reversibility of the airflow limitation, respectively. However, beyond the full reversible airflow limitation which excludes COPD or mixed disease, none of these criteria are fully discriminatory. Patients with some of the characteristics of both diseases should be classified as mixed disease. A definitive diagnosis however, should only be assigned in a dynamic process. Once diagnosed the patient should be continuously re-evaluated according to the strength of the diagnosis, since the consequent treatment is important: COPD patients with asthmatic phenotype need early inhaled corticosteroids, even if their FEV1 > 50 %. Moreover, allergen avoidance can be indicated. On the other hand, asthma patients with COPD phenotype could benefit from anticholinergics or--if indicated--pulmonary rehabilitation. Mixed disease should be diagnosed as the coexistence of two distinct entities, i. e. asthma (allergic or intrinsic asthma, whichever is appropriate) and COPD.

High-altitude climate therapy reduces local airway inflammation and modulates lymphocyte activation.

High-altitude climate therapy is a well-established therapeutic option, which improves clinical symptoms in asthma. However, little is known about the underlying immunological mechanisms. The study investigates the influence of high-altitude climate therapy on airway inflammation and cellular components of specific and unspecific immune response. Exhaled NO significantly decreased within 3 weeks of therapy in patients with allergic and intrinsic, moderate and severe asthma. Interleukin-10 (IL-10)-secreting peripheral blood mononuclear cells (PBMC) increased within 3 weeks of therapy in six of 11 patients, whereas transforming growth factor-beta(1)-secreting PBMC remained stable. Furthermore, monocyte activation, assessed by CD80 expression significantly decreased during therapy. The frequency of CRTH2-expressing T cells decreased, while regulatory T cells (T(reg)) remained stable. FOXP3 and GATA-3 mRNA expression in CD4(+) T cells did not change, while interferon-gamma and IL-13 mRNA expression decreased in eight of 10 patients. The current data demonstrate that high-altitude climate therapy reduces local airway inflammation. Furthermore, monocytes switch towards a tolerogenic phenotype under high-altitude climate therapy. The T(reg)/Th2 ratio increases; however, because of the absence of antigens/allergens, no de novo differentiation of Th2 nor T(reg) cells is observed. The high-altitude climate therapy therefore may form the immunological basis for the endogenous control of allergen-driven diseases.

[Clinical significance of gastrooesophageal reflux in asthma]. / Klinische Bedeutung des gastroösophagealen Refluxes beim Asthma bronchiale.

In clinical practice, gastrooesophageal reflux (GER) and bronchial asthma often coincide. In the case of sufficient asthma control, the asthma does not need to be taken into account when treatment of GER is being evaluated. In patients with symptomatic asthma despite adequate antiasthmatic treatment, a possible causal relationship between GER and the poor responsiveness to asthma therapy has to be considered. An algorithm to guide the diagnostic and therapeutic steps in such cases is presented.

Distinct leucocyte redistribution after glucocorticoid treatment among difficult-to-treat asthmatic patients.

Difficult-to-treat asthma (DTA) represents a heterogeneous subgroup of asthma. Up to now, the lack of specific diagnosis not only complicates appropriate specification and control of asthma, but also makes targeted research difficult. The aim of this study is to categorize this heterogeneous group of DTA patients (n=27; referring to the GINA guidelines) based on the distinct leucocyte redistribution (LR) after glucocorticoid (GC) treatment. Furthermore, the effect of adjuvant therapies was investigated for its impact on LR. The frequency of CD3+, CD4+, CD8+, CD14+, CD19+ and NK cells was analysed in peripheral blood before and 3 h after systemic GC treatment, along with the markers of activation HLA-DR and CD25. Within 3 h of GC administration, a significant average decrease of 16% in CD3+CD4+ (P < or = 0.001) and a 12% increase in NK-cell frequency (P < or = 0.001) clearly distinguished two groups of patients: LR-responsive and LR-unresponsive patients. The CD3+CD8+ T-cell number and activation marker remained unchanged. Patients who received adjuvant therapy, such as methotrexate or interferon-alpha, because of poor clinical response to GC showed an LR similar to that showed by responsive patients. DTA patients comprise at least two immunologically distinct groups: patients showing an immediate decrease in CD3+CD4+ T cells and an increase in NK cells following GC administration and patients lacking an immediate change. Analysis of LR not only may allow the identification of immunologic steroid resistance, but also may be of value for immunologic determination of effective steroid doses.

[Allergic bronchopulmonary aspergillosis (ABPA)]. / Die allergische bronchopulmonale Aspergillose (ABPA).

ABPA is the most common allergic bronchopulmonary mycosis in humans. The diagnosis of the complex disease is based on defined criteria. Five clinical stages of ABPA were proposed. The extend of the defined criteria varies in the different stages, thus making diagnosis difficult. Particularly the discrimination of ABPA in remission stage (stage II) and allergic asthma with A--sensitisation may be an important problem. Early diagnosis in stages without persistent changes of bronchial wall and lung parenchyma is needed to prevent severe end stages of ABPA. The up to now widely used commercial (crude) allergen extracts for in vitro and in vivo diagnosis show batch to batch variation, insufficient standardization and lack of reproducibility. Potentials and limitations of routine diagnostic procedures in ABPA are described. The production of a panel of recombinant allergens of A. fumigatus and their evaluation for in vivo and particularly in vitro use has brought an important step forward in the early and precise diagnosis of ABPA. A panel of recombinant allergens is now available for routine assay in CAP-System.

[Allergic bronchopulmonary aspergillosis (ABPA)]. / Die allergische bronchopulmonale Aspergillose (ABPA).

Allergic bronchopulmonary aspergillosis (ABPA) is the most common allergic bronchopulmonary mycosis in humans. The diagnosis of the complex disease is based on defined criteria. Five clinical stages of ABPA were proposed. The extent of the defined criteria varies in the different stages, thus making diagnosis difficult. Particularly the discrimination of ABPA in remission stage (stage II) and allergic asthma with A. fumigatus-sensitisation may be an important problem. Early diagnosis in stages without persistent changes of bronchial wall and lung parenchyma is needed to prevent severe end stages of ABPA. The up to now widely used commercial (crude) allergen extracts for in vitro and in vivo diagnosis show batch to batch variation, insufficient standardization and lack of reproducibility. Potentials and limitations of routine diagnostic procedures in ABPA are described. The production of a panel of recombinant allergens of A. fumigatus and their evaluation for in vivo and particularly in vitro use has brought an important step forward in the early and precise diagnosis of ABPA. A panel of recombinant allergens is now available for routine assay in CAP-System. Glucocorticosteroids play a central role in therapy of ABPA. The approach in exacerbation phase and the long term therapy are described and also the indication for antimycotic drugs.